November 14–15, 2023, T1DX‐QI Learning Session, Journal of Diabetes Abstracts

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Background: Smart insulin pen (SIP) can improve consistency and accuracy of insulin dosing.Its uptake has been slow in children with diabetes.We participated in the T1DX-QI Collaborative Project to increase shared decision making and equitable access of SIP use.Methods: Between December 2022 and April 2023, we implemented three major interventions with four clinicians: (1) the Diabetes Technology Assessment tool (not specific to SIP), (2) pictorial handout of diabetes technologies, and (3) diabetes technology sample boxes to provide visual and tactile demonstrations (SIP, insulin pod, pumps, and sensors).We tracked changes in technology usage after the intervention was implemented.In parallel, our center partnered with the SIP (Inpen) manufacturer to pilot a new workflow.This workflow included an instruction booklet, sample pen, virtual training, while the vendor seeks insurance authorization.
Results: Between December 2022 to April 2023, we documented 45 total share decision making instances (N = 31 for type 1, N = 45 for type 2 diabetes; 18 already using continuous glucose monitor [CGM]), of which 64% (N = 29) resulted in proposed changes in technology.65% (N = 19) elected to trial CGM, 28% (N = 8) showed interest in insulin pump, and 20% (N = 6) showed interest in SIP technology.Among patients interested in the latter, none initiated SIP.Barriers to SIP initiation included copay requirement, lack of insulin cartridge samples in clinic to facilitate inclinic device training, and poor responsiveness when trainer reaches out to family.Conclusions: Successful implementation of SIP may require minimizing cost and infrastructure to facilitate pen initiation during the clinical encounter.Keywords: Diabetes mellitus, type 1; diabetes mellitus, type 2, shared decision making; insulin pen Abstract #8 Reducing requirements for pump referral improves pump initiation for publicly insured patients Brian Miyazaki; Jennifer Baldwin; James Connard; Jose Aceves; Casey Berman; Jessica Ferris; Rebecca Ortiz La Banca Barber; Debbie Miller; Lily C. Chao Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA bmiyazaki@chla.usc.eduBackground: Conventional process (CP) for insulin pump initiation strives to optimize insulin doses prior to obtaining insurance authorization.Disparity in completion of the CP exists in publicly insured patients with type 1 diabetes (PWD).We hypothesize that reducing requirements for insulin pump initiation will improve pump access and reduce health inequity.Methods: We created a new pathway (NP) for insulin pump referral for PWD, consisting of a virtual informational session conducted in English, collection of twoweeks of glucose readings, and two phone calls with a diabetes nurse.Pump training was conducted virtually.Data was collected from patients over 6 months at a large urban children's hospital.We compared insulin pump clearance, initiation, and insurance status between patients in the CP and NP.Fisher's exact test and student t-test were used for analysis, with p < 0.05 considered significant.
Results: The demographic data from CP (N = 63) and NP (N = 34) were comparable in gender (54% vs 52%) and insurance status (public insurance 71% for both).Pump clearance occurred more commonly in NP (p = 0.015).There was no difference in pump initiation among those who completed requirements (p > 0.999).Patients with public insurance were 5.6-times as likely to initiate insulin pump in the NP (p = 0.0023, 95% CI 1.817 to 17.90).Conclusions: Reducing requirements for insulin pump improves access for publicly insured patients.Future studies are needed to determine if outcomes differ in patients from diverse language and social-economic status.Keywords: Type 1 Diabetes, Insulin Infusion Systems, Health Equity Abstract #9 Developing a tracking tool for continuous glucose monitor prescriptions among children and young adults with type 1 and type 2 diabetes Methods: The Diabetes Support Program (DSP) implemented at CHOA in 2016 aims to reduce acute diabetes complications in patients at high-risk, defined as more than 2 DKA (diabetes ketoacidosis) events within 12 months, or at-risk, defined as 1 DKA within 12 months (diagnoses event excluded).DSP includes a psychologist, a dedicated clinical diabetes educator (CDE) and social worker.Technology utilization has not been a focus.With the addition of 3 providers and 3 CDEs, patients within the DSP population interested in pump technology with insurance that approves closed-loop systems were approached for enroll-Background/Objective: Transition of care (TOC) for adolescents and emerging adults (AEA) with type 1 diabetes (T1D) is complex.Despite consensus on the need for transition preparation, implementation strategies to initiate and sustain a program remain limited.The purpose of this quality improvement (QI) initiative is the development and maintenance of a pediatric T1D transition program over time.Methods: A multidisciplinary QI team identified key drivers consistent with Got Transition guidelines including: (1) establishing expectations for families and staff, (2) integrating transition readiness assessment into clinic workflow, and (3) documenting transition plan and longitudinal tracking.Interventions with iterative PDSA cycles addressed each of these drivers.Primary outcome of % AEA with documented transition plan was tracked over time using a run chart.A convenience sample of patients was followed to track post-transfer outcomes.Results: Cincinnati Children's Diabetes Center adopted a transition policy, developed standard tracking, uses READDY assessment tool, documents transition planning, partners with adult receivership practices, and uses a care coordinator to confirm successful transfer.Over 5 years the percentage of patients with T1D ages 15-18 years with a documented TOC plan increased from 10% to 80% and over age 19 years with documented TOC plan from 20% to over 90%.Mean age of transfer of convenience sample (n = 54) is 22 years; one-year post-transfer HbA1c value was stable.Conclusions: Improving the percentage of AEA patients with TID with documented TOC plans is feasible and sustainable using QI methods supported by diabetes specific transition readiness tools and care delivery processes.Keywords: Diabetes Mellitus, Type 1; Pediatric Transition to Adult Care Abstract #12 Mind the gap: Lessons learned from addressing inequities in CGM Access Nana-Hawa Yayah Jones; Amy Grant; Sarah Corathers; Laura Smith; Jennifer Kelly; Amanda Riley; Desireé N. Williford; Kyle Kaplan; Amanda Howell Cincinnati Children's Hospital Medical Center Cincinnati, Ohio, USA nana.jones@cchmc.orgBackground/Objective: In healthcare mind the gap refers to addressing health disparities.Inequities in rates of healthcare utilization and adverse outcomes are systematically overrepresented in patients from marginalized communities.Our diabetes team is working diligently to close these gaps-specifically by promoting the use of diabetes technology.Methods: Between June 2021 and 2023, we implemented several targeted strategies: barriers assessment; CGM sampling program; DEI training; listening sessions; onsite pharmacy and DME distribution; shared decisionmaking tool; social determinants of health screening; targeted patient outreach; and voice of the customer videos.Health-equity-focused QI tools and Iterative Plan-Do-Study-Act (PDSA) cycles were used to monitor and assess implementation, impact, and improvement opportunities.Health outcomes were collected via patient registry.Data were stratified by race and insurance.
Results: CGM usage among patients identifying as Black increased from 38% to 63% and from 65% to 86% for those identifying as White (reduced gap by 4%).CGM usage among patients on public insurance increased from 56% to 80% and from 77% to 89% for patients on private insurance (reduced gap by 12%).Mean HbA1c for patients on public insurance decreased from 9.4% to 8.9% and from 9.9% to 9.6% for Black patients.Background: Pediatric diabetes ketoacidosis (DKA) has been managed either in the emergency department (ED) or pediatric intensive care unit (PICU) at our institution.Our objective was to establish a moderate care unit on the general pediatrics floor to care for patients with mild-moderate DKA.We hypothesized this shift in our care model would shorten overall length-of-stay (LOS), improving bed availability and reducing patient burden.Methods: We used quality improvement (QI) methods to map the current state and proposed moderate care workflows.Members from pediatric endocrinology, hospital medicine, ED, and nursing reviewed the proposed workflow and collaborated with pharmacy, phlebotomy, and information technology staff to ensure all elements of the workflow could be executed.The team collaboratively developed educational materials and delivered training for residents, nurses, and attending physicians.Patients with "mild-moderate DKA" were characterized as those with a pH on a venous blood gas (VBG) of ε7.2 and a serum bicarbonate ε13.Eligible patients were ε5 years old.Patients meeting these criteria were transitioned to moderate care.Background: The American Diabetes Association (ADA) guidelines for management of type 1 diabetes (T1D) recommend targeting time in range (TIR) ≥70% (blood sugars between 70 and 180 mg/dL) along with <4% time in hypoglycemia (below 70 mg/dL) as optimizing TIR reduces microvascular complications of diabetes.The overall aim of this project is to improve TIR among our patients using a continuous glucose monitor (CGM) by increasing point-of-care TIR education at quarterly clinic visits from 0% to 95% over 12 months.Methods: Our interdisciplinary quality improvement team identified a knowledge gap among our patients related to TIR goals.Through several plan-do-study-act (PDSA) cycles, we created and tested a patient/family education handout, an electronic health record (EHR) SmartPhrase that can be included in after-visit instructions, and questions about TIR goals with associated education in our EHR visit flowsheet, to standardize the process of discussing and documenting TIR goals, education, and patient/family knowledge about TIR.We are currently scaling these interventions across the division.Results: Since beginning the project in January 2023, we have increased the proportion of patients with T1D we discussed TIR goals with from 0% to 72.6% (Figure 1).The median proportion of patients meeting TIR goals (≥70% in range) is 19.2%.Conclusions: Developing patient education materials and standardizing documentation about TIR goals increased provider-patient discussions about TIR.During this short period, we have not yet seen a change in the Background: Without diabetes education for school staff, diabetes management during the school day can interfere with a child's academic success and emotional well-being.The purpose of this quality improvement (QI) project was to increase school education sessions by 15% each year following the creation of a school education program at a NYC pediatric diabetes center.Methods: Through the creation of a diabetes school liaison our center began establishing a diabetes in school program for schools attended by children at our center.School educational sessions were tracked and surveys, events, and ongoing program evaluations were done.Multiple Plan-Do-Act-Study (PDSA) cycles were performed and included: creation of a school liaisonspecific email/phone, initiation of monthly zoom sessions, remote and in-person education sessions at individual schools, and a post-diagnosis school management class.
Results: In year one (2020-2021) of the program, 26 schools received individual in-person or remote diabetes education sessions, 35 sessions in 2021-2022 (38% increase) and 42 in 2022-2023 (17% increase).Survey responses showed 52.9% of the school professionals (27/51) reported they had limited education and understanding prior to education sessions regarding diabetes technology proficiency.Conclusions: There is an unmet need for diabetes education for school educators and staff, and with ongoing support.Our findings show a program for school educators and staff was well received.Additionally, school nurses report a need for education on diabetes technology.Ongoing QI initiatives should continue to improve the education available to schools.Keywords: Type 1 Diabetes, Type 2 Diabetes, Schools, Nursing, Quality Improvement Abstract #19 The design of the electronic health record in type 1 diabetes centers: implications for metrics and data availability for a quality collaborative

Donna Eng
Helen Devos Children's Hospital, Grand Rapids, MI US donna.eng@helendevoschildrens.org and the team Background/Objective: The optimal design of the Electronic Health Record (EHR) is critical for ensuring the quality and reliability to capture data and improve care and outcomes.We sought to describe EHR tools and workflows which contribute to core quality metrics in the T1DX Quality Improvement Collaborative (T1DX-QI).Methods: We conducted interviews with 13 T1DX-QI centers about their EHR tools and clinic workflows.Results: Thirteen centers had access to structured data tools, nine had access to patient questionnaires and two had integration with a device platform.There was significant variability in measure specification, tool use, and workflow, thus the number of available metrics per center ranged from 4 to 15.A greater number of centers had information about glycemic outcomes and diabetes technology use, but fewer centers had measurement of other selfmanagement behaviors.Centers did capture patient reported outcomes including social determinants of health (n = 9), depression (n = 11), transition to adult care (n = 7) and diabetes distress (n = 3).A variety of stakeholders including diabetes providers, CDCESs, medical assistants, and quality improvement coordinators were responsible for capturing data.Centers that had a paired staffing model to support joint involvement of diabetes CDCESs in clinic encounters distributed the burden of data capture across the healthcare team, and was associated with a higher number available of data elements available.Conclusions: Further work is needed to address the lack of standardization in EHR data elements, tools, and workflows, to support measurement and subsequently improved quality of care and outcomes for individuals with T1D.Keywords: Electronic Health Record, quality improvement, type 1 diabetes, workflows, metrics Methods: A multi-disciplinary team was assembled to co-design a structured in-person and virtual follow-up program including clinical, social, and health coaching services.4 PDSA cycles have been completed.The statistical analysis was done with GraphPad Prism 9.5.A paired t-test was performed to assess HbA1c changes.Results: A total of 14 youth were referred to IDEAS and 11 attended the initial IDEAS visit.Mean age 13.9 ± 1.8 years, 64% M, 57% white non-Hispanic, 36% black non-Hispanic, 7% Hispanic, 71% public insurance, 50% using CGM, 7% using an insulin pump, mean HbA1c 12.2 ± 2.5%.The most common etiology for DKA was insulin omission (85%).After improvements in scheduling, 100% of those referred to IDEAS attended (6/6).A total of seven participants had a repeat HbA1c ≥1 month (mean 3.1 ± 1.3 months) after baseline.There was a trend towards reduction in HbA1c (13.1% vs 10.8%, p = 0.16) (Figure 1).All participants consulted with a LMSW, 1 completed health coaching which was associated with a reduction in HbA1c (À1.9%).One participant had a history of 5 DKA episodes in the prior year and has had 1 DKA admission after enrolling in IDEAS.This participant has not been admitted to the hospital in past 4 months and HbA1c has decreased from 14.4% to 12.3%.

Conclusion:
Youth with repeated episodes of DKA who have a standardized follow-up program with clinical, social, education, and health coaching support may have improvement in diabetes follow-up and outcomes.Keywords: type 1 diabetes, diabetes ketoacidosis, quality improvement Abstract #21 Establishing social determinants of health screening to improve pediatric diabetes patient outcomes Blake Adams; Margaret Shepherd; Fatina Caldwell-Jones; Grace Nelson University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, TN USA blake.adams@lebonheur.orgBackground/Objective: Our mission at Le Bonheur Diabetes Clinic is to partner with families to aid them in finding the best ways to manage their children's diabetes.Patients with lower income and education levels have been shown to have worse glycemic outcomes.Despite this correlation between social factors and diabetes management, our clinic was not previously screening for Social Determinants of Health (SDOH) for people with type 1 and 2 diabetes (PWD).To address this disparity, we implemented SDOH screening for PWD with a goal to screen 10% of eligible PWD and offer resources and/or referrals to those who screened positive.Methods: We met as a multidisciplinary team to establish screening parameters and partnered with the University of Michigan and utilized their "Partners in Care" survey.We implemented the survey and screened eligible PWD who had an A1C of ≤ 9.5%.Our social worker followed up with positive screens and provided resources based on individual family needs.Patients who screened positive for issues such as food insecurity, housing instability, transportation barriers, healthcare financial strain, and so forth, were referred and connected with appropriate resources.Results: We successfully implemented SDOH screening for PWD.During our first two testing cycles, of the PWD who were eligible for screening, 59% completed screens.50% of the completed screens were positive, and 81% of the PWD that screened positive were offered referrals to social workers and connected with appropriate resources.Conclusions: Standardizing our SDOH clinic processes helped us increase screening rates and connect PWD to essential community resources.Keywords: Social Determinants of Health, Health Equity Abstract #22 Incorporating shared decision-making to facilitate equitable insulin pump use among pediatric patients with type 1 diabetes Grace Nelson; Blake Adams University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, TN USA gbazan@uthsc.eduBackground: Technology use has improved outcomes for patients with T1D.However, race disparities exist.This was evident by the discrepancy in non-Hispanic Black patients (NHB) on insulin pumps (7%) versus non-Hispanic white patients (NHW) (21%) in our clinic.Our goal is to safely and equitably increase the number of patients using insulin pumps.Methods: We identified a group of NHB patients who were not candidates for starting insulin pumps based on our clinic's "typical" practice but showed interest in pumps.After demonstrating efficacy and safety of pump use in this group, we expanded outreach.Beyond continued education for nurse educators and changing pump start criteria, we also used shared decision-making to ensure that all patients could regularly discuss technology use with their providers.Results: As of December 2022, we have helped >35% of our interested patients navigate the process of obtaining insulin pumps.Equity was improved, with 22% of our NHB patients using pumps and 27% of NHW patients.Some of these patients would not previously be candidates for pumps but were able to safely begin using this technology because of these interventions.
Conclusions: Utilizing shared decision-making can help to identify patients who might not initially be considered for technology.We have demonstrated that many interested patients can safely initiate pumps which will help improve their diabetes management.We are continually adjusting our processes to improve equity in pump use and increase the number of patients utilizing pumps in our clinic.

Abstract #23 Appointment lag time and tracking transition in young adults
Sean DeLacey; Naomi Sullivan; Laura Levin; Naomi R. Fogel Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA sdelacey@luriechildrens.org Background: Transfer from pediatric to adult providers is a sensitive time for Type 1 Diabetes care and is part of a transition process that should start early.If transition is not appropriately discussed, transfer of care is often frustrating for both patients and providers.Delay in transfer can lead to gaps in care and sub-optimal outcomes.Methods: To improve transition of care we began quality improvement efforts, which included the development of a transition policy, recording of transition discussion in clinic, and tracking transfer within a patient registry including date of adult provider appointment.Data was collected via a diabetes registry between September 2021 and March 2023, with efforts to improve transition/ transfer of patient care beginning in February 2022.Results: As of March 2023, there were 186 patients ≥20 years old in the diabetes registry and 95 (51%) had transfer recorded, while 77 (41%) had confirmed appointments.The average time between last pediatric and first adult appointment was 4.72 months (standard deviation 3.26 months).Over time from 9/2021 to 3/2023 an average of 3.6 patients saw a new adult provider per month.In the 6 months before our efforts started, 12 patients had confirmed transfer and in the 6 months afterwards, 29 had confirmed transfer (Figure 1).Conclusions: Starting to discuss transition in a structured way and the development of a transition policy led to an improvement in rates of transfer of care.Continued efforts will focus on patient skill development and facilitating transfer to decrease transfer lag time.Objectives: Diabetes mellitus (DM) is a challenging chronic medical condition requiring active participation of patient/families in self-care.The objective of this project was to initiate family-centered groups for DM patients/families focused on sharing perspectives to improve diabetes management.Methods: DM team members meet with patients/families 2-3 times annually with dinner provided.Agenda items are preplanned and topics that have been discussed thus far include but are not limited to diabetes daily management, sick day management, DM technologies, school diabetes resources, medical handicap/insurance, and psychosocial strategies and resources for coping with DM.Our groups encompass diversity in age, gender, ethnicity, race, socio-economic backgrounds, allowing for families to correlate their experiences with other families.Results: Session participation has demonstrated encouragement in a desire of patients/families to increase the use of technology for diabetes management, improve emotional support, develop coping mechanisms, decrease difficulty with social determinants of health, and improve health literacy.Additionally, this allowed the DM team to identify areas for practice change.Some of the feedback testimonials include: "I do not feel alone," "Great to feel our feedback matters," "We are all on different paths but still have some similarity".

Conclusion:
The sentiments expressed showcase what a difference inclusion of families in these sessions can make in the daily lives of our patients with diabetes.This concept of inclusion of patients and families in their clinical care may also be beneficial in management of other chronic medical conditions.We plan to continue to augment further these sessions in the future.

Abstract #25 Pre-visit diabetes device data capture
Edelina Cohen; Michael Natter; Lauren Golden Center for Diabetes and Metabolic Health at NYU Langone Health New York, NY, USA edelina.bustamante@nyulangone.org Background/Objective: Diabetes device data capture is essential for effective and efficient patient care.Our practice identified a deficit in pre-visit diabetes device data capture.To address this, strategies to improve pre-visit downloads/uploads ("data") were implemented with the aim of increasing device data capture prior to patient visits.Methods: The patient care coordinator (PCC) collected the glucose data prior to patient visits from November 2022 to mid-April 2023.A five-day notice was sent to patients via MyChart with instructions on how to download their diabetes device (continuous glucose monitor, meter, insulin pump, or smart pen) reports and upload as an attachment on MyChart, if not already linked to share their data with our practice.The PCC placed a follow up call 24-48 h prior to the patient's visit to remind them to download/upload their diabetes device data or link their device with the practice.Results: Prior to intervention, approximate data capture was 43%.After intervention, data capture peaked at 65%, with an average of 52% over 24 weeks.harrismi@ohsu.eduBackground/Objective: NICH, or Novel Interventions in Children's Healthcare, addresses the barriers to care and access in young people living with diabetes who also experience a disproportionate amount of social burden.NICH has successfully secured contracts with insurers using data, demonstrating significant cost savings in youth experiencing the highest needs and highest risk.However, despite the compelling results around cost savings, NICH has not been uniformly adopted by insurers and healthcare institutions.The aim of the project was to identify key outcomes that drive contracting for NICH services for youth living with diabetes and high social risk.Methods: We conducted a retrospective qualitative review of contracts with insurers for NICH services delivered to young people living with diabetes.We identified the most compelling outcomes that resulted in establishing contracts for NICH.Results: The results of our retrospective review identified five distinct, but related outcomes that resulted in successful contracting for NICH; reducing costs and medical waste, improving care, improving health, improving provider experiences with care, and decreasing health disparities and inequities.In addition, we identified several barriers to contracting for NICH for youth with diabetes experiencing high cost, high needs, and high risk.Conclusions: Despite data demonstrating the incredible cost savings of NICH, the uptake from both healthcare systems and insurers has been slow.To more successfully establish care for our most vulnerable youth living with diabetes, programs must be able to demonstrate value across several domains including savings, health outcomes, improved care, provider wellness and reducing disparities.Keywords: Diabetes, health disparities, social drivers of health Abstract #28 Improving food insecurity screening in children and adolescents with type 1 and type 2 diabetes Jennifer Ruiz 1 ; Jeannie S. Huang 1,2 ; Jacob Parker 1 ; Yesenia Parker 1 ; Anna Cymbaluk 1,2 ; Christy Byer-Mendoza 1 ; Kim McNamara 1 ; Andrea Huber 1 ; Carla Demeterco-Berggren 1,2 1 Rady Children's Hospital, San Diego, 2 University of California, San Diego San Diego, California, USA cdemeterco@rchsd.orgBackground/Objective: Families raising a child with diabetes face higher health care costs and are more likely to be food insecure.We embarked on a Quality Improvement (QI) project to increase the percentage of youth with diabetes screened for food insecurity (FI) and provided FI resources from 27% to 50% in 12 months.patients with T1D using an insulin pump from 30% to 40% in 15 months.Methods: A T1D data dashboard within the electronic health record (EHR) allowed our team to identify the percentage of public insured patients with T1D seen in diabetes clinic using an insulin pump.A multidisciplinary team identified key change concepts.These were tested in a series of PDSA cycles.Interventions included: offering virtual pump education, providing pump education with Spanish translation, adding additional classes, educating providers regarding implicit bias, increasing patient access to pump information material, and including questions about interest in insulin pump on the clinic intake form.Results: As of June 2023, the percentage of public insured children with T1D utilizing an insulin pump increased from 30% in April 2022 to 42% in June 2023 (exceeding our goal of 40%); (Figure 1.) Conclusions: Continued follow-up of this population will help identify barriers to insulin pump access and the interventions with the most impact.New strategies to address inequities and improve technology use in TID are needed.Keywords: health inequities.insulin pump, pediatrics, type 1 diabetes Abstract #30 Using quality improvement to reduce loss-to-follow-up in pediatric patients with type 1 diabetes Meenal Gupta*, Yasi Mohsenian, Alissa Roberts, Faisal Malik *Seattle Children's Hospital/University of Washington, Seattle, WA, USA meenal.gupta@seattlechildrens.org Background/Objective: Regular ambulatory diabetes clinic visits offer opportunities for individualized education and development of tailored treatment plans to support the management of type 1 diabetes (T1D).Higher rates of clinic visit attendance is associated with lower HbA 1c levels.We aimed to reduce the mean loss-to-follow-up (LTFU) rate for our pediatric patients with T1D to 20% from a baseline of approximately 35% in 18 months.Abstract #31 Screening for social determinants of health in adults with diabetes Ruth S. Weinstock 1 , Emilie Hess; Beth Wells; Jamie Romeiser 1 SUNY Upstate Medical University, Syracuse NY, USA weinstor@upstate.eduObjective: To evaluate adults with type 1 (T1D) and type 2 (T2D) diabetes for social determinants of health (SDOH) and acceptance of social work (SW) referrals.Methods: Food, housing, transportation insecurities and financial resource strain were assessed in adults with T1D and T2D from August 2022 to April 2023.If a need was identified, referral to SW was offered.Exploratory multivariable logistic regression was used to assess for predictors of positive SDOH screening and SW referral acceptance.Results: Of 4704 adults with diabetes, 83.2% (n = 3912) were screened for SDOH (T1D n = 1434, T2D n = 2478).T1D vs T2D adults were younger (mean 41 vs 63 years), mostly White (90.0%vs 73.0%), and had more private insurance (57.9% vs 28.5%): all p < 0.0001.Overall, 13.4% T1D vs 16.0% T2D adults screened positive (p = 0.03); for food insecurity 5.4% vs 7.5% p = 0.01; transportation needs 3.8% vs 4.1% p = NS and financial resource strain 9.7% vs 11.4% p = NS.Adults who screened positive were more likely to be Black vs non-Hispanic White, the majority had >1 material need, and for T1D were more likely to have Medicaid/Medicare and less likely to be using an insulin pump.Of those who screened positive, 25.5% of T1D and 25.3% of T2D accepted SW referrals (p = NS).Those T2D who were White had lower odds of accepting SW referral.Every additional positive insecurity increased the odds of accepting SW referral (T1D OR = 1.39,T2D OR = 1.5).Conclusions: Material needs are common in adults with diabetes.Interventions are needed to address these needs and improve diabetes care.Keywords: Social determinants of health, type 1 diabetes, type 2 diabetes, social work Abstract #32 Higher anxiety scores associated with glycemic outcomes Margaret Gillis 1 ; Emma Ospelt 1 ; Saketh Rompicherla 1 ; Ann Mungmode 1 ; Nicole Rioles 1 ; Alissa Roberts 2 ; Caleb Schmid 3 ; Tamara Hannon 4 ; G. Todd Alonso 5 ; Osagie Ebekozien 1,6 1 T1D Exchange, Boston, MA, USA; 2 Seattle Children's Hospital, Seattle, WA, USA; 3 Oregon Health and Sciences University, Portland, OR, USA; 4 University of Indiana School of Medicine, Indianapolis, IN, USA; 5 University of Colorado, Barbara Davis Center, Aurora, CO, USA; 6 University of Mississippi School of Population Health, Jackson, T1D Exchange, Boston, Massachusetts, USA mgillis@t1dexchange.org Background/Objective: The goal of this study was to look at how anxiety may impact A1c levels.The GAD-7 is a seven-question anxiety screener scored from 0 to 21.These scores are broken down into four categories: minimal, mild, moderate, and severe.For this analysis, we combine mild, moderate, and severe. 1 Methods: This study analyzed EMR data from patients who completed the GAD-7 screener from April 2017 to June 2023.The population of interest consisted of 693 patients from 9 clinics between 12 and 75 years.We combined anxiety categories mild to severe as elevated anxiety levels and compared that to minimal anxiety with chi-square or fisher exact tests.The anxiety levels were analyzed into subcategories to compare based on gender, race/ethnicity, insurance type, and A1c outcomes. 2Similar analysis was performed on the population with A1c > 9%.
Results: There was a significant difference ( p = 0.04) between individuals with A1c > 9%, 38% in the elevated anxiety group and 30% in the minimal anxiety group (Figure).In the A1c > 9% group, there was a significantly higher ( p = 0.004) female population in the elevated group at 66% compared to the minimal group at 48%.There were no significant differences found in race/ ethnicity or insurance type.Conclusions: This data shows elevated anxiety has a higher percentage of its population with A1c > 9%.In addition, within the population with A1c > 9%, a significantly higher percentage of females have elevated anxiety levels.Results: Since the protocol introduction, 95% of our patients with T1D use a glucose sensor and 53% use an insulin pump.Transition to a greater use of technology was facilitated by directly addressing patient concerns about visibility of devices and out of pocket expenses.We also found an easier transition to technology when our team helped patients navigate dealing with insurance, pharmacies, and schools.Conclusion: Transition to a greater use of technology can be facilitated when there is a strong emphasis on its use at the time of diagnosis and at each visit.Anticipating and addressing all the patients' concerns also plays an important role in the transition to greater technology use.Keywords: Barriers, health disparities, technology use, type 1 diabetes hypoglycemia, along with the timing and dosing of insulin for blood glucose corrections.While patients also listed timing and dosing of insulin as a key topic to be reinforced, there was also emphasis on carbohydrate counting and return to "day-to-day life."Conclusions: Survey data emphasizes the need for streamlined diabetes education, as well as the importance of patient involvement and perspective.Our team will continue to collect survey data to better understand topics of confusion and implement appropriate intervention.Next steps include developing diabetes educational videos, as well as a family focus group to involve families in diabetes practice initiatives and decisions.

Figure 1 .
Figure 1.Average Length of Stay (LOS) in Hours After Implementing Moderate Care Workflow (May 1, 2022-June 30, 2023) Compared to Previous Year.

Figure 1 .
Figure 1.Proportion of patients with T1D asked three questions during visit about time in range (TIR): definition/target range, goal for in range, and goal for hypoglycemia.
Abstract #20 Integrated diabetes education and support (IDEAS) program Anna Neyman; Kathryn Haberlin-Pittz; Tamara Hannon Indiana University School of Medicine, Indianapolis IN, USA aneyman@iupui.eduBackground/Objective: To improve education and support for patients with post diabetes diagnosis DKA, we established the Integrated Diabetes Education and Support Program (IDEAS).

Figure 1 .
Figure 1.Percentage of diabetes device data captured prior to visit.
Figure 1: Percentage of youth with type 1 or type 2 diabetes screened for food insecurity and provided with resources.
Methods: A multidisciplinary team developed and tested quality improvement (QI) interventions to improve clinic visit attendance: (1) Training medical assistants to schedule return-to-clinic appointments by the end of the patient's diabetes clinic visit; (2) Offering visit scheduling to patients via Epic MyChart and FastPass; the latter enabled patients with existing appointments to get on a waitlist for an earlier appointment; (3) Adding a new diabetes provider to our team to improve access and availability of clinic visit slots.LTFU was defined as having their last clinic visit >6 months ago.Several Plan-Do-Study-Act cycles were conducted for each intervention.Rates of LTFU were analyzed monthly via statistical process control charts (p-charts) to identify special cause variation.Results: Our baseline LTFU rate was 35% (Figure).Following QI interventions, our LTFU rate demonstrated a downward trend beginning in October 2022 with eight out of the nine next data points below the mean.Special cause variation was identified in May and June 2023 with LTFU rates outside of the control limits.Conclusion: By improving scheduling processes and visit access using QI methodology, we successfully reduced mean LTFU rate.Keywords: Lost to follow up, Quality Improvement, Type 1 Diabetes

Figure 1 :
Figure 1: Percentage of public insured youth with T1D using insulin pump.
Figure 1.Comparison of anxiety levels with patients that have A1c > 9%.
Keywords: Diabetes Mellitus Type 1, Pediatrics, Patient Advocacy, Patient Discharge Abstract #45 DiabetesWise Pro diabetes device digital platform Korey K. Hood Stanford University School of Medicine, Stanford, CA, USA; Stanford Diabetes Research Center, Stanford, CA, USA kkhood@stanford.eduBackground:DiabetesWise Pro is a digital platform for healthcare professionals (HCPs) that aims to (1) increase Awareness diabetes devices, (2) provide Education about matching devices to patient preferences and needs, and (3) simplify the Prescription process.The primary purpose of presenting at the November Learning Session of the T1D Exchange is to identify potential partners interested in testing DiabetesWise Pro in their clinical settings.Given the robust QI Collaborative, there may be opportunities to submit DiabetesWise Pro to the QI process to optimize its use in practice.Methods: Both digital platforms are funded through grants from the Helmsley Charitable Trust, which allows DiabetesWise to be free, unbranded, and unbiased.Dia-betesWise features a device check-up, device finder, wisdom, and other resources for people living with diabetes.The patient (or person) facing website launched in June 2019.DiabetesWise Pro was built and launched in February 2023.Results: The features on the Pro website include a device library, comparison tools, myth-busting resources, and a prescription tool.The prescription tool is the core component of the Pro site that aims to simplify the prescription process for HCPs.Only 3 inputs are needed-device type, location, and insurance planto produce critical outputs which give HCPs access to coverage details, prior authorization forms, pharmacy/ DME information, and policy documents for all FDAapproved devices.Conclusions: This work has the potential to optimize diabetes device prescribing, enhance patient understanding and adherence, and ultimately improve diabetes management outcomes in real world primary care/family practice settings.Keywords: DiabetesWise, diabetes devices, CGM, insulin pump, automated insulin delivery

Division of Pediatric Emergency Medicine; ^Division of Pediatric Hospital Medicine, University of Michigan, Ann Arbor, MI, USA nelliesa@med.umich.edu
Conclusions: Multi-faceted, targeted interventions and QI methodology resulted in improved CGM utilization while simultaneously improving glycemic outcomes in T1D patients by race and insurance.Iterations of these interventions have demonstrated the importance of redesigning innovative, transformative, and inclusive healthcare solutions in partnership with patients.
Access to DR screening in clinic, education of patients and providers, and improving data collection and EHR tools increased DR screening rates.Future interventions will expand screening to adults and further reduce barriers to screening.Keywords: Diabetes complications, diabetes retinopathy, pediatrics Technology has had a profound benefit in the management of patients with T1D.Despite the availability of technology through most third-party payers, racial and ethnic disparities have been reported.Methods: In our pediatric T1D clinic, approximately half of our patients are Hispanic or Black.Half of our patients are insured by Medicaid.We found disparities in technology use with greater utilization among white patients.To rectify this, we introduced a protocol designed to ensure that all our patients receive advantages of technology.All patients were prescribed glucose sensors at diagnosis.Established patients who did not use a sensor were strongly encouraged to use one with sensor placement at the visit.Smart pen usage was recommended for all patients soon after diagnosis.Insulin pump was encouraged 6 months after diagnosis for patients proficient in carbohydrate counting.
Eligible patients who completed DR screenings increased to 30.1% by May 2023.Conclusions: